Quality of General Practice

key findings for GPs from an independent inquiry

The report of an independent inquiry, commissioned

by The King’s Fund, has concluded that there are significant opportunities for general practices in England to improve the quality of care they provide to patients. Here we outline the key findings for professionals in general practice and describe the central role that general practice must now play to improve quality of health care.

›› new responsibilities for assessing and meeting the health needs of the local population ›› new relationships with neighbouring practices and other local stakeholders to deliver highquality care ›› a more equal partnership with patients in which they are supported to become active participants in the care and services they receive.

General practice: moving centre-stage in a reformed NHS The report of the inquiry comes at a time of significant change for general practice. Proposed reforms of the NHS mean that general practice will play a key role as both commissioner and provider of care. General practitioners are being asked to take on new responsibilities for ensuring the provision of cost-effective and high-quality care to patients that extends well beyond the confines of their surgery walls.

When The King’s Fund commissioned the inquiry two years ago the economic and political climate was very different. However, the core aims of the inquiry are probably even more important today: to examine the current state of care quality in general practice; to produce practical ideas for how high-quality care could be promoted; and to set out the challenges for general practice in meeting the quality agenda.

Defining the challenge The radical developments set out in the coalition government’s reforms have far-reaching implications for general practice. GPs will need to take on: • new responsibilities for assessing and meeting the health needs of the local population • new relationships with neighbouring practices and other local stakeholders to deliver high-quality care • a more equal partnership with patients in which they are supported to become active participants in the care and services they receive.

These changes will come at a time of unprecedented social and economic pressure, marked by: • a rapidly ageing population and associated numbers of people living with one or more chronic conditions • major cuts in public spending • increased demands from more informed patients • technological advances that challenge current ways of working.

What the quality of care in general practice looks like today The inquiry set out to make an overall assessment of the quality of care in English general practice, based on specially commissioned research and analysis of routinely available data. While the inquiry concluded that the quality of most care in general practice is good, it uncovered evidence of wide variations in performance and gaps in the quality of care both within and between practices.

The inquiry concluded that many of those working in general practice were not aware of such variations and that significant opportunities existed for general practice to improve the quality of care it provides, particularly in the following areas.

• Long-term conditions Recommended care is not delivered reliably to all patients, particularly those with multiple and long-term conditions. The quality of care could be improved significantly by introducing more proactive and preventive care that would allow for earlier diagnosis and treatment and avoid unscheduled hospital admissions.

• Continuity of care Evidence suggests that in recent years patients have found it more difficult to see the primary care professional of their choice at a time that suits them. This necessitates an open conversation about how best to balance demand for faster access to services and continuity of care.

• Co-ordination of care There is a fundamental need to improve how care is co-ordinated between general practice and other care settings, particularly for vulnerable patients such as those with complex and long-term needs, and those at the end of life.

• Patient involvement and engagement Patients remain poorly engaged in making decisions about their own health and more could be done to support them in making choices, sharing decision-making and caring for themselves. Evidence presented to the inquiry suggests this can have a positive impact on care and outcomes.

• Prescribing Not all GPs and practices prescribe in line with best practice, which impacts on cost-effectiveness as well as quality.

There is clear evidence that more effective prescribing is possible – for example, the prescribing of low-cost statins. More could also be done to support patients to ensure they take their medication appropriately.

The inquiry’s report calls for action by general practices to embrace quality improvement, and for the government to ensure that a system of care is developed that rewards high-performing practices. A better and more consistent standard of care is possible, and practices that underperform need to be challenged to improve and supported to do so.

Owning the quality agenda The fundamental message of the inquiry’s report is that general practice needs to own the quality agenda and take on professional leadership for quality improvement in general practice.

Here are some of the ways GP consortia and individual practices can facilitate that process: • use data and information tools to provide clinicians with the knowledge they need to identify and prioritise areas for quality improvement • develop an open culture that balances the ability to challenge with the need to support.

General practice is more likely to engage in driving care improvements when data is shared transparently at local level with patients, the public and professional peers • foster strong clinical leadership in order to develop the clear vision and shared values through which effective collaboration and teamworking can flourish • provide the training and support needed to implement quality improvements, along with protected time and incentives • introduce a system of reward and penalties for member practices that is genuinely influential and focused on local priorities.

How general practice needs to change

Further information

Many general practices are proactively looking at ways to improve care; however, quality improvement is not yet embedded as a way of working and practices need support in creating an environment in which it can flourish. From the evidence presented to the inquiry, it is clear that meeting the quality challenge will require general practice to adapt significantly.

We hope that those working in general practice will find the report useful both in understanding where there are gaps and variation in quality and in pointing to practical ways in which the profession as a whole, practice teams and individual professionals can make positive changes to services.

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Changing the skill-mix in general practice Almost all general practices now work as health care teams. GPs must focus their skills on those patients with more complex problems, drawing on specialist support during the consultation process, and in the planning and delivery of care. GPs should continue to work closely with practice nurses, health care assistants and other team members whose roles will be enhanced over time.

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Sharing care with hospital and community services General practice needs to act as the hub of a wider system of care and must take responsibility for co-ordinating and signposting patients to services beyond health care. General practice must work more closely with hospital and community services in order to co-ordinate care – particularly for those with longterm conditions.

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Striking a new deal with patients General practice needs to strike a new relationship with patients in which they become active participants in the care and services they receive; effective engagement with patients is fundamental to quality improvement.

The King’s Fund provides a range of information and publications for those interested in the quality of care. We also run programmes specifically aimed at developing skills and leadership in GPs and other health professionals.

If you would like to read a copy of the full report or find out more about the work of the Inquiry please visit: www.kingsfund.org.uk/gpinquiry If you would like to register for regular updates about our work in primary care or other aspects of health care visit: www.kingsfund.org.uk/updates If you would like to contact the inquiry project team direct you can contact us by email at: gpinquiry@kingsfund.org.uk If you are interested in finding out more about The King’s Fund’s work in leadership development you can contact us at: leadership@kingsfund.org.uk

Meeting the health needs of the wider population High-quality care is not just about meeting the needs of people who present themselves but is also about reaching out to those who need care but may not seek it. General practice in the future also needs to be more proactive in preventing ill health and working with local authorities and wider public services to improve the health of local communities as well as to reduce health inequalities.

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From cottage industry to post-industrial care General practice needs to adapt so that it operates at a scale that can deal with the increasing demands placed on it. The infrastructure of primary care delivery has changed little over the past decades. There is an urgent need to accelerate the work to establish practice federations, and to bring isolated practices more formally into larger provider organisations or networks. These new organisations must focus on measuring performance, improving care standards, and transparent reporting.

The King’s Fund (2011). Improving the Quality of Care in General Practice. Report of an independent inquiry commissioned by The King’s Fund. London: The King’s Fund.

The inquiry was chaired by Sir Ian Kennedy, Emeritus Professor of Health, Law and Ethics at University College London and Chair of the Independent Parliamentary Standards Authority. The other members of the independent panel were Dr Michael Dixon, Chair, NHS Alliance; Professor Steve Field, former Chairman of Council of the Royal College of General Practitioners; Professor Ursula Gallagher, Borough Director and PEC Chair, NHS Ealing; and Dr Rebecca Rosen, Senior Fellow, The Nuffield Trust.